When I first met Mr. Brunetti *, his skin was bright yellow. He had finally come to the hospital, after some coaxing from his family, because he was feeling a little tired and nauseated, and because his color seemed a little off. He was found to have an enormous mass in his gallbladder, which had already metastasized. He had advanced stage cancer. Even if you know nothing about medicine, you can probably surmise that the prognosis for this is quite poor.
I went to see him every single morning, and pretty much just sat next to his bed and let him talk. Asking him the usual review of systems questions, outside of whether he was comfortable or not, seemed a waste of time. He was struggling with trying to make a decision: Should I go through chemotherapy? Should I get radiation? Should I do nothing? I dutifully listened to him, confident only in the fact that I had none of the answers.
We had begun to discuss what he wanted to do, but in his mind, the decision was still theoretical. This person we were talking about who had cancer was someone else. A month ago, he was just a 74-year-old man with hypertension. Now he was a man with less than a year to live, at best. From our morning conversations, I knew that he didn’t want anything to be done. “I’ve had a happy life. Of course I want it to be longer, but it isn’t going to be. I have five beautiful grandchildren, and I just want to spend more time with them. I don’t want to put my family through treatments. I’ve seen people coming into the hospital for chemo – that’s no way to live.” However, he continued to request to be full code and he mentioned to me that his granddaughter had suggested he enter a clinical trial in another country.
I was distressed by my powerlessness in helping him officially verbalize his decision and come to terms with his diagnosis. We had gotten an oncology consult; he had a GI surgeon seeing him, and now palliative care was talking to the family as well. Although the family seemed mostly in agreement to just keep him comfortable, they were not ready to say the words that made the decision final.
One morning I came in and Mr. Brunetti had had an awful night. He was bleeding from his cancer, he was weak, and he was unable to make it to the bathroom before losing control of his bowels. He was ready. We gathered his paperwork, called palliative care, and we all met in his room. We discontinued all his lab orders, ordered his pain and nausea medication, set up his appointment with hospice, and changed his code status to DNR/DNI.
As I walked out of his room, I heard him talking about me. “That girl has been in to sit with me every single morning. She is very nice.” He didn’t say, “That is my doctor and his medical care has been wonderful,” or “That’s the palliative care lady and I’m glad she helped me make my decision.” I was the one he associated with this process, and it was not a negative association. I felt an overwhelming sense of relief. What a privilege to have been the one to go through this experience with him.
As I write this, my eyes well up with tears, but I’m not sure if they’re tears of sadness, joy, relief or just sheer emotion. There is nothing like spending time with a dying patient and being there for that moment of peace when they decide it is okay to let go. I think about him every single day, now, and how, somehow, I am in a position to listen to people’s innermost secrets, wishes and thoughts. I am in a position to change the course of someone’s final days, and this has absolutely nothing to do with my medical knowledge of the disease process. My conclusion from this whole experience is clear. Sharing in the death experience with a patient is the greatest privilege I have thus far been granted.
*Name and some details have been changed to protect patient confidentiality.